1679756290 NPI number — MR. JONATHAN CLARK REDDING BCBA

Table of content: MR. JONATHAN CLARK REDDING BCBA (NPI 1679756290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679756290 NPI number — MR. JONATHAN CLARK REDDING BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REDDING
Provider First Name:
JONATHAN
Provider Middle Name:
CLARK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REDDING
Provider Other First Name:
JONATHAN
Provider Other Middle Name:
CLARK
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BCBA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1679756290
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
373 S WILLOW ST STE 266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03103-5751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-315-8080
Provider Business Mailing Address Fax Number:
877-345-4009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3152 ANCHORWAY CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALLS CHURCH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22042-7549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-315-8080
Provider Business Practice Location Address Fax Number:
877-345-4009
Provider Enumeration Date:
12/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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